On July 9-10, The American Health Quality Association (AHQA) convened national partners working to improve healthcare quality in Baltimore, MD for the 2018 AHQA Quality Summit. Honored to have attended as a James Q. Cannon Fellow, I spent these two days learning from expert speakers and peers about strategies for continued healthcare quality improvement through community awareness, innovation and collaboration.

Being a first-time guest to Baltimore I wandered nearby Inner Harbor with our group on Sunday evening and—in true tourist fashion—gaped at the Maryland Science Center, the World Trade Center Institute Baltimore, the USS Constellation, Camden Yards and much more. I also tried the much-acclaimed crab cakes which, for the record, absolutely live up to the hype.

Over the next two days I made countless connections between my work as part of Lake Superior Quality Innovation Network (QIN)(link is external) in Michigan and the impactful work being done by fellow attendees and presenters nationwide. Below are takeaways from sessions I attended including new perspectives to apply to my work as a member of Lake Superior QIN. As these summaries are somewhat brief, I encourage you to visit the 2018 AHQA Quality Summit webpage for a complete list of sessions  and presentation slides.

The Science of Burnout and Well-being in Healthcare: How Other People Matter, Kathryn C. Adair, Ph.D.

Dr. Adair, social psychologist with the Duke Patient Safety Center(link is external), began the Summit by discussing the science of burnout and wellbeing in healthcare. With many demands and limited time facing healthcare providers in our current system, this topic was extremely timely and inspired conversation throughout the rest of the Summit. Study data presented during this session drove home the quiet ubiquity of healthcare provider burnout, specifically in:

• Critical care nurses: half are emotionally exhausted, two out of three have difficulty sleeping, and one out of four are clinically depressed.
• Surgeons: 8.9 percent reported making a major medical error in the previous three months (reporting an error had significant correlations with all three domains of burnout).
• Medical students: half are burned out, nearly half report excessive fatigue and 10% percent have suicidal ideation (compared to 3.7 percent in the general population).

In addition to the impact of burnout Dr. Adair also discussed environmental correlates that act as buffers, or “burnout band aids,” including (but not limited to) social support, a positive learning environment, satisfaction in conversation with others and positive working relationships. To address and prevent healthcare provider burnout—as well as strengthen workforce resilience—Dr. Adair recommended implementing both institutional and personal interventions.

Personal reflections:

• “Focus determines your reality” and “perceptions are influenced by how you feel” – our internal environments influence what we contribute to and take from daily interactions.
• As Quality Innovation Network-Quality Improvement Organization (QIN-QIO) staff, we are in a prime position to reduce healthcare provider burnout by aligning initiatives with clients’ priorities including quality reporting programs, unique community needs and payment mechanisms.

Takeaways for my work as part of Lake Superior QIN:

• Support provider and partner resilience to prevent burnout and promote project sustainability
  • Continue to provide technical assistance (TA) that accounts for and optimizes workflow.
  • Recognize success in fostering teamwork and positive working environments.
  • Encourage “positive rounding” in internal and client meetings/huddles to recognize what’s going well and individual/organizational successes.

Find strategies, slides and references from this presentation here.

Driving Change and Moving Toward the Future: Looking Ahead for the QIO Program, Jeneen Iwugo, MPA and Paul McGann, M.D.

Jeneen Iwugo, MPA and Paul McGann, M.D. from the Quality Improvement & Innovation Group in the Center for Clinical Standards and Quality at CMS discussed results achieved from the current 11^thScope of Work to date and future directions for the QIO program(link is external).

National progress made so far in the 11^th Scope of Work includes:

• 350,000 fewer patient harms, 8,000 lives saved and more than 2.9 billion in cost savings.
• 18.7 percent reduction in antipsychotic medication use in residents living in long-term care facilities.
• 91 percent of MIPS eligible clinicians, 98 percent of accountable care organizations and 94 percent of MIPS eligible clinicians in rural practices submitted data for the 2017 performance year.
• Prevented 46,000 hospital readmissions and contributed to $600 in cost savings throughout 387 communities.
• Educated 5,300 providers and 48,662 Medicare beneficiaries completing diabetes self-management education.

With more to come!

Potential focus areas for the next Scope of Work were shared including workforce burden reduction, improving behavioral health including opioid abuse, improving chronic disease management (cardiovascular, diabetes, CKD-ESRD), increasing patient safety, increasing quality of care transitions and long-term care. Proposed focus areas resulted from public input and CMS’ Agency priorities and would incorporate rural health, vulnerable populations and patient and family engagement as cross-cutting priorities.

Find more QIN-QIO programming results, future directions and slides from this presentation here.

Reducing Provider Burden with an Integrated Outpatient Services Approach, Sharon Donnelly, M.S. and Sharon Phelps, R.N., BSN, CPHIMS

Sharon Phelps from Mountain-Pacific Quality Health Foundation(link is external) and Sharon Donnelly from Qualis Health(link is external)/HealthInsight(link is external) described their many partnerships, collaborations and considerations in working with providers on their QIN-QIO task work. A two-pronged approach presented consistent focus on reducing burden for providers and internal staff, including:

Programming for outpatient providers is streamlined by grouping interventions into four core categories—advance care planning, annual wellness visit, transitional care management and chronic care management—within a framework of current and new payment mechanisms. The session described work designs that incorporate collaboration, alignment, big picture thinking and technology solutions that successfully break down programming silos and build on clients’ priorities and goals.

Takeaways for my work as part of Lake Superior QIN:

• Continue to regionalize task TA to promote consistency and meaningful evaluation.
• Support burden reduction by optimizing health information technology in practices and empowering providers to use available EHR functionalities to input and act on data.

Find more on this integrated services approach and slides from this presentation here.

A QIN-QIO Collaborates with Academia: Engaging Small Practices in Blood Pressure Control, Joanne Vanterpool, MBA and Susan Hollander, MPH, CPHQ

During this session, Susan and Joanne presented their work on Project Implementing Million Hearts for Provider and Community Transformation (IMPACT).(link is external) Started in 2014, this initiative centers on Million Hearts®(link is external) goals with a focus on improving blood pressure control and cardiovascular outcomes in the South Asian community cared for in primary care settings across New York City. Project partners provide TA and subject matter expertise to targeted practices, including:

• Evaluating use of community health workers (CHWs) and EHR functionalities and interventions.
• Testing and implementing CHW and EHR-based tools targeting Million Hearts® goals.
• Developing and implementing culturally tailored provider training programs to empower direct care staff to improve hypertension control.

Personal reflections:

• A theme continues – Joanne and Susan described an approach to programming that aligns initiatives and incentive programs and supports optimizing practices’ resources (improving patient care and outcomes + minimizing burden).

Takeaways for my work as part of Lake Superior QIN:

• Utilize lean approaches to drill down to root causes of providers’ challenges in caring for patients with chronic conditions.
  • Example: is a practice’s percentage of patients with controlled blood pressure (BP) (NQF 0018) persistently low?
    • Asking The Five Whys(link is external) may reveal that inconsistent staff technique for manual BP measurement may be overestimating patients’ BP and assistance is needed to facilitate competency training.
    • Example based on findings from a root cause analysis in Michigan (before my time) that contributed to regional collaboration on Lake Superior QIN’s Hypertension Management Toolkit(link is external).

Find more on programming approach and Project IMPACT here.

Overarching theme – the opioid epidemic

In addition to burden reduction, the opioid epidemic(link is external) was also a common theme throughout multiple sessions, including:

• Opioid Performance Improvement Project in Nursing Homes: Utilizing a Virtual Collaborative to Drive Results, with Amanda Ryan, PharmD, BCGP.
• Reduction in Opioid Prescribing Through Evidence-Based Prescribing Guidelines, with Joceline Vu, M.D. and Gloria Pizzo, R.N., BSN.
• Opioid Guardianship: Combating the Opioid Crisis, with Sarah Derr, PharmD and Meg Nugent, MHA, R.N.
• CMS’ Jeneen Iwugo, MPA and Paul McGann, M.D. also shared strategies(link is external) employed within a current Special Innovation Project to address opioid misuse and behavioral health disorders in Southwestern Ohio.

These sessions issued a clear call to action to attendees to continue national work with healthcare providers on prevention efforts and rapid response projects to support quality care and patient safety.

Connecting and collaborating

In addition to presentations highlighting quality improvement program successes, I attended a brainstorming breakout session called “Collaborate & Solve!”, facilitated by AHQA Executive Director, Alison Teitelbaum, M.S., MPH, CAE. During this session, we identified common challenges in our work and split up into small groups to discuss lessons learned. My group explored work silos both within our organizations and with stakeholders:

• The issue: groups don’t always see value in collaboration (possibly due to organization cultures, fear of change, etc.).
• Brainstorming – what we have seen work for silo breakdown:
  • Researching the landscape and taking advantage of existing groups, advisory boards and coalitions (statewide and regional).
  • Listening to partner and stakeholder experiences (learn vs. reinventing the wheel).
  • Coordinating so that joint efforts become comfortable and keeping communication open (regular touch base calls) about what is going on and continued interest in partnership.
  • Uniting under the understanding that we can’t reach everyone we want to reach without partnering.

One point presented by one of my fellow brainstormers stuck with me both personally and for my work as part of Lake Superior QIN: “It’s amazing what you can accomplish when you don’t care who gets the credit” – Harry Truman.

Find additional small group topics and discussion notes here.

Reflections and thanks

As I reflect on my first experience attending the AHQA Quality Summit, I’m left with broadened perspectives and a great sense of purpose and gratitude. I want to express sincere thanks first to the AHQA Board of Directors and all involved in the development of the James Q. Cannon Memorial Scholarship for the opportunity to attend this year’s event and for investing in early career professionals. Thank you to all those involved in the planning and successful execution of the 2018 Quality Summit as well as the speakers who dedicated their time and expertise to make this a truly educational and engaging event. Finally, thank you to my fellow attendees for inspiring me to a wider perspective on our work and its continued importance – I hope we meet again at future summits and out in the field with our boots on the ground, continuing to support quality healthcare nationwide.

The AHQA 2018 Quality Conference was a great time for healthcare professionals and leaders to collaborate and learn about the issues most pressing in healthcare today.

The conference opened up with K. Carrie Adair, from Duke University who presented on The Science of Burnout and Well-being in Healthcare: How Other People Matter. This was a great way to open up the conference because burnout is applicable to everyone, in every field, not just healthcare. Adair captured the audience by presenting on the meaning of burn out and how humans are just generally tired. Most notably, she focused in on nurses in healthcare and shared some alarming statistics on nursing burnout. Sure, we all know the healthcare industry is full of professionals who are burning out and overworked, but when you put it in a graph it is distressing. In critical care in particular, half of the nurses are “emotionally burnt out” 1 out of 3 have trouble sleeping, and 1 out of 4 are clinically depressed (Sexton, et. Al. (2009).Palliative Care). She shared some interesting studies paired with crowd participation on how humans are trained to see the negative. It was eye opening, and definitely a great way to start a conference, Bravo!

The rest of the two days were filled with breakout sessions on various hot topics in the healthcare industry. Of course, there was a fair share of presentations and breakout sessions on opioids. One of the biggest topics of the healthcare field today.

Sara Derr, PharmD and Meg Nugent, MHA, RN presented on behalf of the Iowa Healthcare Collaborative on the IHC Opioid Guardianship Project. Another stand out for me in opioids, was Amanda Ryan, PharmD, BCGP from Atom Alliance’s presentation on Opioid Performance Improvement Project in Nursing Homes: Utilizing a Virtual Collaborative to Drive Results.

The AHQA Quality Conference was a two-day event filled with many healthcare quality improvement professionals sharing ideas, collaborating and discussing the future of healthcare. Alongside some Medicaid and CMS representatives giving us the insight on the future of CMS’ Quality Improvement initiatives, timelines and expected outcomes. Jeneen Iwugo and Paul McGann, MD presented on Driving Change and Moving Toward the Future: Looking Ahead for the QIO Program. Being part of a QIN-QIO myself, I was most interested in this presentation. Iwugo and McGann thanked us for our hard work, commitment and for improving the quality, safety, and delivery of care to Medicare beneficiaries. They talked about the future of our work, and the bold aims they plan to set. Well, we look forward to seeing those aims, and discussing our success at them at the AHQA Quality Conference in 2019!

Improving the quality of healthcare is meaningful, important, life-changing work, but it can also be very challenging. As quality improvement professionals, supporting one another through peer-to-peer sharing and collaborative relationships is critical to success. It takes all of us with unique perspectives and expertise to facilitate the changes needed to continue making healthcare better.

AQHA is a key piece of the professional support needed to change healthcare in America, and the annual AHQA Quality Summit provides a place to receive and share that support with others working to improve healthcare quality. I was honored to attend the 2018 Quality Summit in Baltimore as a recipient of a James Q. Cannon Memorial Scholarship. At the summit I met and exchanged ideas with quality improvement professionals from around the nation. Some were people I have spoken to on the phone many times, and putting a face to the name strengthened those relationships. Others I had never met, and we all left with a larger and stronger network of support. Attendees also had the opportunity to interact frequently with AHQA staff to share successes and request support with challenges in quality improvement work.

Peer-to-peer sharing was available in the many breakout sessions, with topics ranging from reducing provider burden, to patient and family engagement, and medication safety. Most relevant to my work as a pharmacist were the sessions on opioid safety. Hearing from QIN-QIOs and others on their successful work in this area is now helping to shape our opioid work at the atom Alliance QIN.

As we near the end of the 11th SOW, it was helpful to hear from Dr. Paul McGann and Jeneen Iwugo from CMS in a plenary session on the future of the QIO program. Another plenary focused on workplace resiliency and the importance of showing gratitude to reduce burnout. As all of us work together to change lives for the better through higher quality healthcare, these skills will be key for us to practice and share with others.

I encourage you to attend the Quality Summit in 2019. As QIN-QIOs transition into the next scope of work, our capacity to change healthcare and the corresponding challenges will continue to increase. The Quality Summit provides the resources, relationships, and support we need to bring patients and communities the healthcare they deserve.

The Centers for Medicare & Medicaid Services (CMS) offers two types of visits covered by Medicare: The Welcome to Medicare preventive visit and an Annual Wellness Visit. During these visits, primary care physicians develop and update a personalized prevention health plan based on a patient’s health and risk factors determined from a Health Risk Assessment (HRA). As part of the HRA, patients and providers review various behavioral health risks, including mental health and alcohol use.1

The TMF Quality Innovation Network Quality Improvement Organization (QIN-QIO), under contract with CMS, offers assistance to physicians in Arkansas, Missouri, Oklahoma, Texas and Puerto Rico with screening for depression and alcohol use disorder under its Behavioral Health initiative. Yolanda Marcos, MD, a primary care physician specializing in Internal Medicine at Marcos Medical Care in San Antonio, Texas, is a participant in the Behavioral Health initiative. Dr. Marcos, her nurses and her medical assistants received technical assistance from a TMF QIN-QIO consultant to become familiar with alcohol and depression screening. Dr. Marcos’ patient visits are spread out throughout the year, allowing her and her team time to conduct a thorough physical that includes screening for behavioral health. Completing the Medicare Annual Wellness Visit has helped the practice do a better job at capturing depression and alcohol-related issues.

Dr. Marcos attests, “[TMF QIN-QIO] giving validity for these screenings and education to the staff was extremely helpful.” Despite her staff already being familiar with screening tools, working with an outside organization like the TMF QIN-QIO only validated the need to screen these patients to effectively provide quality care.

Dr. Marcos also contributed her high screening rates to an application called Phreesia, which sends an email to patients with a set of questions to be answered before their visit. If the patient does not fill out the questions ahead of time, front desk staff gives them a tablet to use in the waiting room. The questions the patients receive are tailored to their specific type of appointment. Patients that are scheduled for their Medicare Annual Wellness Visit will receive the depression and alcohol screening as part of this process, and the questionnaire is automatically uploaded to patient charts upon completion. The medical assistant then reviews the score and enters it into the visit notes for the provider to review with the patients. This workflow helps patients complete the screening questions efficiently, leaving more time for other topics during the visit.

Dr. Marcos has made it her goal to screen patients consistently. Completing the screening is one small part of the process, so she has her team continually assess and modify the workflow to increase the number of screenings across patient populations. Dr. Marcos takes the prevalence of behavioral health disorders seriously, so she aims to improve the quality of care she delivers, regardless if patients are visiting for a Medicare Annual Wellness Visit or not, and address conditions before they escalate. Perhaps the most positive outcome Dr. Marcos has seen from her screenings is that patients have to take charge in order to complete their own screeners. Since Marcos Medical Care has embraced these behavioral health screenings within the practice, the practice has maximized treating the whole health needs of their patients, recognizing that behavioral health and physical health are interrelated.

The graphs below demonstrate the screening rates over two years of Marcos Medical Care’s 3,506 patients among all payer types, including self-pay. Dr. Marcos implemented Phreesia around October of 2016.

Over one million Americans reside in the nation’s 15,800 nursing homes on any given day. Those individuals and an even larger number of their family members, friends, and relatives, must be able to count on nursing homes to provide safe, reliable, high quality care.

The National Nursing Home Quality Care Collaborative focuses on overall quality in nursing homes and uses a data-driven, proactive approach to eliminating or reducing preventable healthcare acquired conditions (HACs) including falls, pressure ulcers, C.difficile infections, urinary tract infections, and inappropriate antipsychotic use in persons with dementia. The collaborative framework provides nursing homes the opportunity to engage in quality improvement work. Nursing home teams can participate no matter where they are on the quality continuum.

The District’s collaborative name and motto is “Mission Possible- Creating Agents for Change”. The AQIN-DC QIO engaged 83% of the state’s nursing home community with key stakeholders from the trade association and our Department of Health partners. We discussed the goals of the collaborative with key stakeholders to ensure alignment with their priorities and goals – an attempt to avoid duplication of effort. This important step provided one message going out to our providers. Teams could focus their energies and not have to answer or respond differently to each organization’s requests.

09/2016 Collaborative One- Outcomes Congress Swearing in of new Mission Possible Change Agents

Our collaborative work began April 2015 and will continue through September 2018. Our approach to engage the participants includes webinars and live LAN events that address:

• CMS’ collaborative change package, goal setting, Model for Improvement and PDSA.
• QAPI principles and implementation.
• Use of data to identify opportunities for improvement.
• Subject matter expert speakers to cover collaborative topics.
• Spotlighting teams and recognizing successes.

Teams receive monitoring and feedback through:

• Technical assistance calls/visits to review progress with selected goals.
• Each team’s senior leaders receives a quarterly facility progress report. Report identifies team’s progress on all collaborative measures, progress on composite score, and collaborative participation.

Results – Collaborative topics selected by most participants from Q4 2014 to Q2 2017

Lessons Learned by All

09/2017 Collaborative Two- Learning Session Two Learning about Antimicrobial Stewardship and Antibiotic Resistance

Teams have embraced the “all teach all learn” framework of a collaborative. Setting goals, monitoring the effects of interventions and sharing those successes has produced significant quality measure reductions in the state. The challenge will always be to rapidly spread the innovations and sustain the gains achieved.

How did we engage our collaborative community to achieve significant improvements? We learned:

• Including key stakeholders early during planning stages for recruiting, and trainings brings benefit with their specific knowledge, people connections and shared resources.
• Assisting providers in addressing immediate needs brings value to NH leadership and key staff.
• Smaller collaborative groups create a sense of community, enhances peer networking, and team sharing.

This material was prepared by the Atlantic Quality Innovation Network (AQIN), the Medicare Quality Innovation Network-Quality Improvement Organization for New York State, South Carolina, and the District of Columbia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 11SOW-AQINDC-TskC.2-17-23

The Centers for Medicare & Medicaid Services’ (CMS) Transforming Clinical Practice Initiative (TCPI) is a key component of the new CMS Quality Payment Program. TCPI is uniquely designed to help 140,000 clinicians nationwide transform their practices from quantity of services to quality of care. Nationally, the 29 designated Practice Transformation Networks (PTNs) are charged with coaching and assisting clinicians in developing core competencies that prepare them to participate in Alternative Payment Models (APMs). In late 2015, 13 Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) were awarded contracts to assist the PTNs operating in their geographic regions. A key role of QIN-QIOs is to assess the clinician practices’ progress through five defined phases of practice transformation, by conducting TCPI baseline assessments and ongoing follow-up assessments for each practice.

‍From the start, Lake Superior QIN – the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) serving Michigan, Minnesota and Wisconsin – put a high priority on establishing strong working relationships with the six PTNs operating in its region, which currently represent 700 practices and 7,000 clinicians. Building trust and creating ongoing communications were instrumental in the process. Project charters defined expectations and identified shared PTN/QIN-QIO measures. Once relationships were established, the Lake Superior QIN-PTN project teams worked collaboratively to develop efficient practice assessment processes – introductions, warm-handoffs, assessment feedback to PTNs and assessment submission to CMS.‍

Bill Sonterre, Lake Superior QIN’s TCPI regional lead, says, “The scope of the areas and processes involved in TCPI transformation is extensive. The assessments, which gauge a practice’s baseline, have been eye-opening for many of the practices. The assessments have shown them what they need to better understand in order to achieve transformation goals; the PTNs provide support to enhance processes to effectively achieve transformation strategies.”

Lake Superior QIN’s TCPI team has completed 253 baseline assessments to date, more than double its annual target of 100 baseline assessments. By July 2019, the QIN plans to complete 400 baseline assessments and 3,913 follow-up assessments. To achieve these ambitious targets, the current plans call for Lake Superior QIN to complete 100 percent of baseline and follow-up assessments for five of the PTNs, and a large percentage of the assessments for the sixth PTN. The strategy also calls for reaching out and supporting any new PTNs that may start operating in the three-state region.

Taking innovative steps, Lake Superior QIN is integrating TCPI with other QIN project work as budgets allow. Sonterre adds, “We’re getting a better feel for what each PTN is focusing on, so we can help the practices with quality improvements and meeting their transformation goals.”

This story is one of 15 that were included in the 2016 QIO Program Progress Report.

When CMS’ QIO Program announced a call for Special Innovation Projects (SIPs) in summer 2015, the Great Plains Quality Innovation Network (QIN) – the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) serving Kansas, Nebraska, North Dakota and South Dakota – seized the opportunity to propose improving screening rates for colorectal cancer (CRC). CRC is the second leading cause of cancer deaths in both men and women and the third most commonly diagnosed cancer in the United States – and a particular threat in the Midwest. The four states served by the Great Plains QIN have CRC incidence rates that are higher than the national average and CRC screening rates that are far below the national average, particularly among the states’ Native American populations.

Since being awarded a SIP contract in September 2015, the Great Plains QIN has been working in support of the National Colorectal Cancer Roundtable’s “80% by 2018” initiative, which aims to reduce the number of new colon cancer cases and avoidable deaths nationwide by getting 80 percent of patients screened in each state. The Great Plains QIN has focused on recruiting clinics that serve the states’ rural and Native American populations, and has worked with those clinics to establish baseline screening rates and a systematic process for providing screening recommendations and reminders. To date, 82 percent of clinics throughout the four-state region have signed the “80% by 2018” pledge. One particular provider in Kansas, PrairieStar Health Center, implemented a consistent screening policy, patient reminders and electronic health record (EHR) notes across its five practices, and has achieved an 84 percent screening rate thus far.

‍Combining CRC screening with other CMS health quality priorities, like immunizations, has proven instrumental to screening improvements in rural areas, where the distance of colonoscopy centers and the lengthy preparation and testing processes, have presented barriers. The Great Plains QIN has helped flu clinics develop FLU-FIT (fecal immunochemical test) programs, offering at-home CRC tests to patients at the time of their annual flu shots. In collaboration with the American Cancer Society(ACS), the Great Plains QIN hosted a FLU-FIT webinar series to help clinics across the four states get FLU-FIT up and running. As a result, 30 sites launched FLU-FIT programs in 2016.

The Great Plains QIN’s partnerships with state, regional and national stakeholders have been a strong foundation for improvement throughout the region. The QIN has aligned with the ACS, local ACS affiliates, Centers for Disease Control and Prevention grantees, the Health Information Exchanges and Colorectal Cancer Roundtables in each of its four states, as well as partnered with the Great Plains Tribal Chairman’s Health Board and local public health units on or near the tribal areas to support efforts to improve CRC rates within the Native American population. “We and our partners share the same three-part aim of better care and better health at lower cost,” says Denise Kolba, RN, MS, CNS, Program Manager for the Great Plains QIN in South Dakota. “We know that improving CRC screening rates will help decrease the cost of treatment for cancers. In 2009, the mean total CRC cost per Medicare beneficiary was $29,196, which included 12 months of care but excluded things like home health and durable medical equipment. Even if we prevent just one case of colon cancer due to early screening in each of our 45 recruited clinics, we’ll save beneficiaries $1.3 million. Our SIP project will pay for itself.”

This story is one of 15 that were included in the 2016 QIO Program Progress Report.

Qualis Health – the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) serving Idaho and Washington – is working to improve quality reporting for clinicians, including those at physician practices and at larger health care facilities.

Critical Access Hospitals in Idaho

In December 2015, the Idaho Bureau of Rural Health conducted a collaborative needs assessment among Critical Access Hospitals (CAHs) that provided insight into their past reporting experiences, challenges and educational needs related to the Physician Quality Reporting System (PQRS), a precursor to the Medicare Access and CHIP Reauthorization Act (MACRA).

“CAHs are community hospitals that have close relationships with their local clinical providers,” says Qualis Health Idaho State Director Linda Rowe. “They have limited resources, so we approached our network of CAHs differently than other hospitals and focused on their unique areas of importance.”

Qualis Health used the information from the Bureau of Rural Health to develop a comprehensive education plan for 10 CAHs that has resulted in approximately 700 providers avoiding nearly $275,000 in penalties and a 43 percent relative improvement in participation of reporting 2016 PQRS data.

As part of its strategy, the QIN-QIO developed educational materials, held community lunch-and-learns at local hospitals across the state, and hosted webinars on aligning physician efforts between PQRS and other clinical goals like Medicare Beneficiary Quality Improvement Project measures and other incentive programs.

‍Qualis Health also developed the MIPS Minute, a 12-part video podcast series with more than 2,200 views as of December 2016, to help facilities and physicians understand the basics as the Quality Payment Program launches in 2017.‍

“Understanding the complexities of MACRA will be essential for physicians and practice staff that care for Medicare patients. The MIPS Minutes videos are an excellent vehicle for building that knowledge base,” a representative of the Washington State Medical Association says.

The QIN-QIO plans to release an updated MIPS Minute series on the final MACRA rules in early 2017.

Idaho is a primarily rural state, which in-and-of-itself can provide unique challenges. The QIN-QIO used a small team approach and leveraged the role of hospitals and providers, many of which are on their own, to foster team support in rural communities. “It takes a team to make quality reporting happen,” says Qualis Health’s Idaho Quality Improvement Consultant Deanna Graham.

The QIN-QIO also worked with key health care stakeholders such as the Idaho Hospital Association and the Idaho Medical Association to share these resources with a broader physician audience.

“As conveners and collaborators, we are thankful that the relationships we have developed in Idaho are moving the needle on quality improvement. We’ve seen many more organizations and providers who now have experience in quality reporting that will be the foundation for their success with the new Quality Payment Program under MACRA,” Graham concludes.

Ambulatory Surgery Centers in Washington

In Washington in 2016, Qualis Health concentrated on ambulatory surgery centers (ASCs), which account for more than 60 percent of all surgical procedures performed in the United States. The QIN-QIO focused on infection prevention – a topic of great interest to ASCs – to engage them in how to use their data for quality improvement purposes and prepare them for pay-for-performance.

Unlike in hospitals, rates of surgical site infections (SSIs) in ASCs are not well known for a variety of reasons, including lack of standard infection definitions for most procedures performed, limited reporting of infections, and inconsistent coding for health care-associated infections in claims data.

However, preliminary analysis of ASC Medicare claims data for Washington shows a rate of 2.85 post-operative infections per 1,000 procedures, which, while low compared to hospital rates, represents a substantial number of adverse outcomes in aggregate, given the high volume of procedures performed in these settings.

‍To engage ASCs and support them in the transition from pay-for-reporting to pay-for-performance, Qualis Health provided half-day infection prevention trainings for approximately 40 ASCs, as well as on-site walkthroughs where possible. The four- to five-hour workshops were interactive and included detailed technical advice relating to care of environment, sequencing of processes, risk assessments and high-level disinfection and cleaning. They also received intensive training on how to use data for quality improvement.

“It’s important for facilities to have scientific tools to gather data they can demonstrate to surveyors and other stakeholders,” says Qualis Health Quality Improvement Consultant Jeff West. “Our focus was on engaging these types of providers on motivating infection control and accurate reporting.”

One day when the clinic was closed to surgery, Qualis Health provided an on-site walkthrough where the entire nursing, technical and administrative staff followed the typical path of patient flow, starting with the waiting room and moving through pre-op, operating room and post-op care.

“ASCs are known for being physician-owned and run with hierarchical structure, thus, we also focused on building communication between various levels of staff with checklists, culture change tools and anything that improves teamwork,” West said.

In 2017, Qualis Health plans to focus on expanding SSI control training with a long series of webinars that repurpose materials and include expert guest speakers as well as QIN-QIO staff.

This story is one of 15 that were included in the 2016 QIO Program Progress Report.

Over the course of a year, the nation’s 15,600 nursing homes provide services to more than three million Americans. To ensure every nursing home resident receives the highest quality of care, Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) and their partners participate in the National Nursing Home Quality Improvement Campaign. As part of the Campaign, QIN-QIOs help nursing homes improve their performance on 13 National Quality Foundation-endorsed quality measures.

In Pennsylvania, home to more than 700 nursing homes, Quality Insights – the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) serving Delaware, Louisiana, New Jersey, Pennsylvania and West Virginia – is piloting state-based Affinity Groups to provide technical assistance and peer learning around select quality measures. Beginning in August 2016, Quality Insights led two small Affinity Groups of nursing homes to concentrate on improving bladder and bowel incontinence. Using the Quality Assurance and Performance Improvement (QAPI) process as a framework, nursing home staff met virtually every other week using GoToMeeting for intensive sessions focused on forming process improvement teams, completing Root Cause Analyses, conducting Plan-Do-Study-Act cycles, goal setting and ongoing monitoring of the measures, and sustainability. During off weeks, nursing home teams worked together to complete homework assignments to prepare them for the following week’s session. Nursing homes also learned how they can meet residents’ needs by engaging residents and their families in all nursing home quality improvement activities. At the end of the 12-week program, the Affinity Groups celebrated their accomplishments, and nursing homes received certificates of completion.

Preliminary data show nursing homes participating in the Affinity Groups are seeing improvement on their bladder and bowel incontinence measure, according to the nursing homes’ own data tracking. Nursing homes also indicate they are adopting the best practices, tools and resources they received through their participation in the Affinity Group. In 2017, Quality Insights plans to introduce a QAPI Affinity Group for nursing homes that are just getting started with quality improvement, as well as Affinity Groups concentrating on reducing falls and the unnecessary use of antipsychotic medications.

This story is one of 15 that were included in the 2016 QIO Program Progress Report.

Adverse Drug Events (ADEs) are defined as any harm to a patient resulting from the use of a medication – whether the harms stem from medication errors, overdoses, or adverse drug reactions or interactions. ADEs negatively impact patient health in many ways and potentially cause unnecessary hospitalization or death. Yet despite the serious nature of ADEs, the good news is that most are preventable.

With this in mind, Telligen – the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) serving Colorado, Illinois and Iowa – initiated a medication reconciliation project for members of its medication safety care collaborative in response to their feedback, which indicated that “medication reconciliation and communicating about patients’ medication lists” are some of their biggest challenges involving medication safety for their patients.

Medication reconciliation is a review of all the medications a patient takes, including doses and frequency of use. “Medication reconciliation should happen at every juncture in the [care] continuum,” says Katy Brown, Program Manager Lead and Clinical Pharmacy Specialist at Telligen. “Not just once, not just twice, but every time the patient interacts with a provider. Every time a med is changed, and every change in level of care demands an accurate list,” says Brown. Doing so significantly reduces the risk of ADEs and unnecessary hospitalizations, she says.

Telligen’s three-part project aimed to reduce ADEs by increasing the frequency of medication reconciliation in a variety of care settings, including hospitals, clinics and community pharmacies. The first part of the project involved gathering general medication reconciliation process data from care facilities. Telligen created a short online assessment that evaluated care facilities’ current medication reconciliation process against best practices. The QIN-QIO then analyzed the collected data and assigned points to each step of the facility’s medication reconciliation process to create an overall score. Using this data, a Telligen pharmacist gave feedback to providers to help them improve their processes.

‍One important recommendation was granting community pharmacists access to discharge medication lists, as these health care providers typically have extensive contact with patients post-discharge. Initially care providers were reluctant to share their medication lists. Providers cited patient confidentiality and legal concerns, time constraints, problems with faxing and more. However, Telligen provided reassurance that medication lists were shared with virtually all other stakeholders in the care continuum, including home health agencies, nursing homes, primary care providers and specialists, among others. In the end, the providers who chose to participate in Telligen’s project saw immediate benefits in communication between patients and caregivers, as well as lower rates of ADEs through this more holistic care approach.

The project was developed and tested during the summer of 2015, implemented in the fall of 2015 and completed in June of 2016. At completion, 15 communities in Iowa and Colorado had used the assessment tool, and approximately 1,350 patient records had been analyzed. Each “community” is a care collaborative comprised of health care providers and social service agencies. Thus far, the project has helped prevent more than 440 potential ADEs.

This story is one of 15 that were included in the 2016 QIO Program Progress Report.